2007 2007 1 Controlling Cost, Delivering Value, Transforming Care CVS Caremark—Our new organization and role as your pharmacy benefit manager 3 A New Approach to Care and Cost Making healthcare simpler, more personal, cost effective, and connected 9 Single-Digit Trend Continues in 2006 Making the most of market opportunities Specialty Pharmacy: 2006 Trend Analysis, 2007 Forecast 27 Dynamic growth continues with a flourishing pipeline and expanding utilization Index 36 2007 Trends Rx® Report Cost, Value & Care Controlling Cost, Delivering Value, Transforming Care In this, the 2007 TrendsRx® Report, we address you as part of a new organization— CVS Caremark Corporation. Our recent merger brings exciting possibilities and new opportunities to impact pharmacy services and improve the value we provide to you, our pharmacy benefit management (PBM) clients. In an environment ever more conscious of the importance of the pharmacy benefit to health and healthcare cost management, our new company is uniquely positioned to serve our PBM customers. As part of CVS Caremark Corporation, Caremark will strive to deliver more cost-effective management for payors; provide greater access, information and choice to consumers; and improve the quality and safety of total healthcare. We’ll share more about this new vision with you in the pages that follow. Herein, we also provide an in-depth look at the factors that drove pharmacy trend in 2006 and preview factors that will affect trend in 2007. Notably, in 2006 we marked ourfourth 2006 Caremark Book of straight year of single-digit Book of Business (BOB) pharmacy benefit gross trend. Business Gross Trend: At 5.2 percent per member per year (PMPY), our 2006 trend declined by well over 2 percent from our 2005 number. 5.2% PMPY Our clients made good use of Caremark programs that promoted last year’s blockbuster generic launches. The BOB generic dispensing rate increased throughout the year. Overall, generics reduced our BOB spend by more than 33 percent in 2006. This year’s report includes detailed reporting on generics and the strategies that will help you take advantage of coming launches. Our role as your pharmacy benefit manager is to support the optimal use of prescription drug therapies to: • Help you control growth of drug spend • Improve outcomes in your covered population • Reduce your total healthcare cost 1 2007 Trends Rx® Report Cost, Value and Care Specialty pharmaceuticals continue to play a significant role in drug spending growth. The sector’s rate of growth has slowed, although it still outpaces the rest of the market. See pages 27–34 to learn more about developments in specialty pharmaceuticals in 2006, as well as our projections for the next 18 months. The implementation of the Medicare drug benefit in 2006 made prescription drugs more affordable for millions of Americans. In many ways, the benefit also accelerated drug price consciousness and visibility in America, while highlighting the essential role pharmaceuticals play in the health and well-being of so many citizens. For many Americans, pharmaceuticals and healthcare—their costs and the value received— remain top concerns despite recent slower rates of growth. Leaders of business and industry, health plans and government believe that changing consumer health behaviors is the key to taming cost growth. Pharmacy benefit management and pharmacy services will have crucial roles to play in the coming years in this transformation of the healthcare environment. At CVS Caremark, we look forward to working with you, the clinical community, and your plan participants and members to optimize the use of pharmaceuticals and healthcare services, thereby improving outcomes and maximizing the value of your healthcare investment. Caremark BOB gross trend is the percentage change in gross drug spend year over year. It measures the components of gross cost change in price, drug mix and utilization over the previous year. Gross trend reflects total prescription cost, including both plan participant and payor portions. Trend is reported on a per member per year (PMPY) basis. All 2006 trend calculations are based on a trend cohort group which includes funded clients with integrated (mail and retail) benefit plans with claims from January 1, 2005 through December 31, 2006 (24 months of claims). Average eligibility must be within +/-15 percent period over period. Trend cohort group excludes Puerto Rico, Virgin Islands and Guam clients, and does not include Medicare Part D members. Gross trend calculations do not take into account projections related to the retiree drug subsidy, which will affect net trend for many of our clients. Calculations for trend without specialty pharmaceuticals exclude the Universal Specialty Drug List. 2007 BOB data, where cited, include Caremark and PharmaCare clients and Medicare Part D plans. The 2007 TrendsRx Report contains prescription brand name drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. 2 2007 Trends Rx® Report A New Approach A New Approach to Care and Cost There’s no question that the United States devotes enormous resources to our healthcare system. The Centers for Medicare and Medicaid Services (CMS) estimate that national health expenditures (NHE) in 2006 exceeded $2.1 trillion and accounted for 16 percent of our gross domestic product (GDP). Per capita spending was just over $7,000. By 2016, the agency expects that the United States will spend more than $4 trillion on healthcare and that the sector will account for just less than 20 percent of GDP.1 Despite the magnitude of this investment, there is broad dissatisfaction. Payors recognize that current levels of cost growth are unsustainable, quality of care is inconsistent and access to care is an issue for tens of millions of Americans. Healthcare coverage and costs are the top domestic issue among consumers according to a recent Kaiser Family Foundation survey.2 By and large, consumers experience the system as complex, impersonal, disconnected, reactive, and increasingly unaffordable. Figure 1 CMS estimates that national health expenditures Market efforts have will exceed $4 trillion by 2016 and account for nearly focused primarily on the 20% of gross domestic product. “system” of healthcare, $1,400 14% such as through vendor $1,200 11.5% 12% negotiations and efficient Annual % Gr $1,000 10% purchasing. Yet, at its $800 8% core, healthcare happens 6.7% 6.9% 6.8% 7.0% 6.6% 6.9% owth NH $600 6% between a patient and $400 4% E a provider. Annual Spend (in Billions) Hewitt, The Road Ahead: $200 2% Emerging Health Trends 2007 $0 0% 1993 2004 2005 2006* 2007* 2011* 2016* Total NHE $912.6 $1,858.9 $1,987.7 $2,122.5* $2,262.3* $2,966.4* $4,136.9* (billions) NHE as a 13.7% 15.9% 16.0% 16.0%* 16.2%* 17.5%* 19.6%* % of GDP Hospital Care Professional Services Prescription Drug Annual % Growth NHE * Projected Source: “Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs, February 2007. Data source: National Health Statistics Group, Office of the Actuary, Centers for Medicare and Medicaid Services; and U.S. Department of Commerce, Bureau of Economic Analysis and Bureau of the Census. Selected NHE components shown. 3 2007 Trends Rx® Report A New Approach Prescription Drug Spending Prescription therapies, of course, are a key factor in healthcare costs. In 2006, CMS estimated that prescription drug spending totaled approximately $214 billion, just under 10 percent of NHE.3 The prescription benefit is the healthcare benefit most used by consumers. In 2006, the average number of retail prescriptions per capita was 12.4. Fifty-nine percent of the population under 65 had a prescription drug expense in 2004, while 92 percent of those 65 and older had such an expense.4 Used appropriately, prescription drugs reduce the incidence of complications and delay or prevent the need for costly hospital, emergency and long-term care for people with conditions such as heart disease, asthma, AIDS, and diabetes. Additionally, these medications can improve the quality of health and life for individuals with cancer, rheumatoid arthritis, multiple sclerosis, schizophrenia, and depression, as well as many other conditions. Less than 10 years ago, prescription drug spending was growing at double-digit rates. That rate of growth has slowed—largely through more effective use of prescription benefit management programs and strategies such as tiered co-payments, promotion of generic Pharmaceutical drugs when appropriate and utilization management. breakthroughs that involve The Opportunity Ahead a precise diagnosis of a As the largest provider of pharmacy services in the country, CVS Caremark plays a crucial role disease and an effective and has a critical opportunity to optimize our clients’ investment in prescription therapies. As a therapy save the system key link in prescription benefit management, Caremark addresses both clinical and economic goals for our clients. Additionally, we are in contact with all stakeholders: consumers, pharmacists, a tremendous amount of physicians, and payors. CVS has the largest number of retail pharmacies in the country, a growing money even though the number of which contain on-site health clinics staffed by nurse practitioners—a delivery model drugs may appear to be with the potential to make care more convenient and reduce overall costs for consumers. In evaluating the potential contribution of our new organization, Caremark reviewed research high-cost. about prescription utilization and disease incidence and found that: Clayton Christensen, professor Harvard Business School, quoted in the • One in every four individuals at risk for a chronic condition such as hypertension is unaware New York Times, December 31, 2006. of his or her risk. Individuals with diabetes may go as long as 12 years before the condition is diagnosed. Without treatment, these individuals can incur irreversible damage to their cardiovascular system.